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Presented by George Netto, MD and prepared by Shien Micchelli, M.D.
Case 6: A 56 year old male presented with a lower gastrointestinal bleed.
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1. Question
Week 258: Case 6
A 56 year old male presented with a lower gastrointestinal bleed. On endoscopic examination, he was found to have a 3 cm rectal villous mass. A biopsy was performed./images/2_27_06_6a.jpg
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/images/2_27_06_6d.jpgCorrect
Answer: Small cell carcinoma underlying a villous adenoma
Histology: On low power examination, a “small blue cell” proliferation is seen underlying a villous mucosal lesion. On higher magnification, the mucosal lesion has features of a villous adenoma without evidence of severe dysplasia. The underlying lesion is composed of sheets of small cells with high nuclear to cytoplasmic ratio. The small cells demonstrate characteristic nuclear molding, scattered apoptotic cells and high mitotic rate. The small cell carcinoma invades the submucosa extends to the edge of the biopsy. As expected, the small cell carcinoma reacted positively with Chromogranin and Cytokeratin.
Discussion: Primary small cell carcinomas of rectum are a relatively rare tumors accounting for less than 1 % of all rectal carcinomas. Their occasional association with an overlying villous adenoma is well documented and could pose a diagnostic difficulty on small superficial biopsies especially when complicated by crush artifact. Immunostains for neuroendocrine markers can be of help in such cases. Like their counterpart in other locations, small cell carcinomas of the large intestine are highly aggressive neoplasms with associated liver metastasis at the time of diagnosis.
Reference(s):
– Bernick PE, Klimstra DS, Shia J, Minsky B, Saltz L, Shi W, Thaler H, Guillem J, Paty P, Cohen AM, Wong WD. . Neuroendocrine carcinomas of the colon and rectum. Dis Colon Rectum 2004 ;47(2):163-9.
– Ispas C, Yu J, Tarantino DR, Lara JF. Pathologic quiz case: a 44-year-old woman with a tubulovillous adenoma of the colon and liver and bone lesions. Small cell (neuroendocrine) carcinoma of the colon with metastasis and an associated, overlying villous adenoma. Arch Pathol Lab Med. 2005 ;129(3):412-4.Incorrect
Answer: Small cell carcinoma underlying a villous adenoma
Histology: On low power examination, a “small blue cell” proliferation is seen underlying a villous mucosal lesion. On higher magnification, the mucosal lesion has features of a villous adenoma without evidence of severe dysplasia. The underlying lesion is composed of sheets of small cells with high nuclear to cytoplasmic ratio. The small cells demonstrate characteristic nuclear molding, scattered apoptotic cells and high mitotic rate. The small cell carcinoma invades the submucosa extends to the edge of the biopsy. As expected, the small cell carcinoma reacted positively with Chromogranin and Cytokeratin.
Discussion: Primary small cell carcinomas of rectum are a relatively rare tumors accounting for less than 1 % of all rectal carcinomas. Their occasional association with an overlying villous adenoma is well documented and could pose a diagnostic difficulty on small superficial biopsies especially when complicated by crush artifact. Immunostains for neuroendocrine markers can be of help in such cases. Like their counterpart in other locations, small cell carcinomas of the large intestine are highly aggressive neoplasms with associated liver metastasis at the time of diagnosis.
Reference(s):
– Bernick PE, Klimstra DS, Shia J, Minsky B, Saltz L, Shi W, Thaler H, Guillem J, Paty P, Cohen AM, Wong WD. . Neuroendocrine carcinomas of the colon and rectum. Dis Colon Rectum 2004 ;47(2):163-9.
– Ispas C, Yu J, Tarantino DR, Lara JF. Pathologic quiz case: a 44-year-old woman with a tubulovillous adenoma of the colon and liver and bone lesions. Small cell (neuroendocrine) carcinoma of the colon with metastasis and an associated, overlying villous adenoma. Arch Pathol Lab Med. 2005 ;129(3):412-4.
